Provider Demographics
NPI:1750169058
Name:FLORES, DIANE STEPHANIE
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:STEPHANIE
Last Name:FLORES
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3004 FITZGERALD RD
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-5235
Mailing Address - Country:US
Mailing Address - Phone:805-304-5317
Mailing Address - Fax:
Practice Address - Street 1:9925 INTERNATIONAL BLVD STE 5
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94603-2558
Practice Address - Country:US
Practice Address - Phone:510-550-2644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-18
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95033757363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily